la Prilocaine Hyperbare Pourquoi Quand Comment

Transcription

1 la Prilocaine Hyperbare Pourquoi Quand Comment E. GUNTZ MD, PhD Hôpital Braine l Alleud Waterloo Charleroi 23 novembre 2013

2 Introduction The journal editors consider all human studies unethical that test drugs intrathecally that have not formally been tested for lack of neurotoxicity. I do agree that some drugs that are used intrathecally on a daily basis and worldwide have never been formally tested for neurotoxicity. Prilocaine does definitely not belong to these drugs. I suggest you invest time and energy in valid animal studies that provide convincing evidence that IT prilocaine is not neurotoxic. We would be very interested in publishing such data

3 Introduction Regional Anaesthesia VS General Anaesthesia Difficult intubation Difficult ventilation Full stomach Old patient High ASA score Obésity Pregnancy Benefices-Risks Balance

4 Spinal Anesthesia Rapid onset Predictable onset Suitable duration of Difficult Intubation Difficult ventilation Full stomach Age sensory ASA score block Rapid Obésity recovery Pregnancy Minimal side effects Introduction General Anesthesia Propofol Remifentanil

5 Introduction Small-dose bupivacaine Failure, Inadequate block height Urinary retention Excessively long time-course to block resolution Hyperbaric Lidocaine 40 years Transient Neurological Symptoms (TNS) 10% Gupta Acta Anaesthesiol Scand 2003 Hampl Anesthesiology 1998 Kamphuis Anesthesiology 1998 Ben David Anesth Analg 1997

6 Introduction TNS are characterized by moderate to severe pain in the buttocksand legs Symptoms develop within a few hours and up to 24 hours after anaesthesia They last, in most cases, up to two days (<5 days) Incidence of TNS are increased by: Patient Position Lithotomy-arthroscopy Early deambulation NOT ADAPTED TO ONE DAY SURGERY

7 80% Introduction

8 Alternatives The new old local anesthetics Short-acting LA surgical spinal block min Chloroprocaine: 1950 Nesacaine Amino-ester, Normobaric Preservative and anti-oxydant free ( Na + bisulfite) Articaine: 1970 Astracaine, Ultracaine Amino-amide, Normobaric Intermediate-acting LA surgical spinal block min Mepivacaine: 1962 Carbocaine, Scandicaine Amino-amide, Hyperbaric TNS Prilocaine: 1965 Citanest Takipril Prilotekal Amino-amide, Hyperbaric Förster Curent Opinion Anesth. 2011

9 16 Randomized controlled trials included (RCTs) 1467 patients 125 TNS The main clinical question addressed by this review is whether lidocaine used for spinal anaesthesia causes symptoms of TNS more frequently than with other local anaesthetics. The answer to this question is: YES.

10 Forest plot of comparison: 1 Lidocane versus other local anaesthetic, outcome: 1.1 Transient Neurologic Symptoms. Alternatives When mepivacaine is excluded The Relative Risk of Lidocaine Induced TNS is : 7.31

11 Alternatives Cousins Neural Blockade 3rd ed.

12 Alternatives 90 rats intrathecal perfusion through catheter T. Yaksh model

13 Alternatives All rats receiving 20% mepivacaine and 20% prilocaine could walk without limitation within 3 hours after the injections No rats receiving 20% lidocaine could walk even at 4 days after the injection

14 2 groups of 30 patients Alternatives

15 Alternatives Absence of transient radicular irritation after 5000 spinal anaesthetics with prilocaine Retrospective correspondance In 1992, we changed to use plain 2% prilocaine at a dosage of approximatively 1mg.kg -1 Since then, approximately 5000 spinal anaesthetics using prilocaine have been performed in our institution but no further cases of transient radicular Irritation have been observed W. König D. Ruzicic Anaesthesia 1997 District Hospital Aarberg. CH.

16 Summary Neurological injuries can occur with every LA TNS can occur with every LA Incidence of neurological injuries and TNS is very low with hyperbaric prilocaine

17 Prilocaine Summary Amide hyperbaric Safe Rapid onset Short duration Rare side effects Why a sudden interest? 1965? Unstable Loss of safety Loss of efficiency Takipril-Priloketal seems stable at room temperature (3 years) Additional actual factors Duration of surgeries are constantly reduced Economy: one day surgery represent 80% of hospitalizations (USA) Social: patients ask for one day surgery Is Prilocaine able to answer to these obligations? IAAS 2009

18 Prilocaine Hendriks BJA 2009

19 50 mg Prilocaine

20 Prilocaine 50 mg 2H 3H 4H

21 Prilocaine 0 MOT SENS

22 20 mg HP-20 µg fentanyl vs 7.5 mg HB-20 µg fentanyl 21 prilocaine spinal injections: 21 arthroscopic knee surgeries Prilocaine

23 Prilocaine 60 mg 23.3% 50 mg: 8.3%

24 Onset time Duration fast median slow Urinary retention TNS short median prolonged rare median frequent rare median frequent HP Lidocaine Bupivacaine Based on symposium ESA 2012

25 Determination of the ED 90 of hyperbaric prilocaïne for intrathecal anaesthesia in day case knee arthroscopy. ED 90 Prilocaine Latreche Guntz 9AP1-8 EJA 2012

26 Determination of the ED 90 of hyperbaric prilocaïne for intrathecal anaesthesia in day case knee arthroscopy. ED 90 Prilocaine Observational study 50 patients Spinal anesthesia was performed with 40 mg of HP. This dose allowed the surgery for 46 patients. 87% 88% 92% Percentage of complete motor blocks Bromage III Percentage of sensory block at T12 dermatome level. The time to reach L1 dermatome level is 5 minutes

27 Determination of the ED 90 of hyperbaric prilocaïne for intrathecal anaesthesia in day case knee arthroscopy. ED 90 Prilocaine Observational study 50 patients Maximal extension of the sensory block

28 Determination of the ED 90 of hyperbaric prilocaïne for intrathecal anaesthesia in day case knee arthroscopy. ED 90 Prilocaine Observational study 50 patients DMB: duration of motor block (time to obtain a Bromage score of 0): 1H30 DSB duration of sensory block (time to obtain the complete resolution of the sensory block): the patient is ready to leave hospital 3H00 TT: time between the injection of HP and the inflation of the tourniquet: 5min BS: beginning of surgery 15 min DS: Duration of surgery?

29 Determination of the ED 90 of hyperbaric prilocaïne for intrathecal anaesthesia in day case knee arthroscopy. ED 90 Prilocaine 88 Patients No hypotension No bradycardia No urinary retention No TNS

30 ED 90 Prilocaine Sufentanil Determination of the ED 90 of hyperbaric prilocaïne with 1µg sufentanil for intrathecal anaesthesia in day case knee arthroscopy. No pruritus No Urinary retention

31 ED 90 Prilocaine Sufentanil Determination of the ED 90 of hyperbaric prilocaïne with 1µg sufentanil for intrathecal anaesthesia in day case knee arthroscopy. Observational study 30 patients

32 ED 90 Prilocaine Sufentanil Determination of the ED 90 of hyperbaric prilocaïne with 1µg sufentanil for intrathecal anaesthesia in day case knee arthroscopy. Observational study 30 patients

33 ED 90 Prilocaine Sufentanil Determination of the ED 90 of hyperbaric prilocaïne with 1µg sufentanil for intrathecal anaesthesia in day case knee arthroscopy. DMB: duration of motor block (time to obtain a Bromage score of 0): 1H00 DSB duration of sensory block (time to obtain the complete resolution of the sensory block): the patient is ready to leave hospital <3H00 TT: time between the injection of HP and the inflation of the tourniquet: 9min BS: beginning of surgery 20 min DS: Duration of surgery?

34 Determination of the ED 90 of hyperbaric prilocaïne with 1µg sufentanil for intrathecal anaesthesia in day case knee arthroscopy. ED 90 Prilocaine Sufentanil 55 Patients No hypotension No bradycardia No urinary retention No TNS 1 pruritus

35 Prilocaine Cases and recipies Knee Arthroscopy: 40 mg 30 mg + 1µg sufentanil Saphenectomy: 60 mg 48 mg + 3µg sufentanil Uterin revision: 20 mg + 2.5µg sufentanil Hysteroscopy, cystoscopy: mg Clou gamma, triple vissage: 40 mg 30 mg + 1µg sufentanil Césarienne?

36 Prilocaine vs Chloroprocaine?

37 Prilocaine vs Chloroprocaine? There is a Place for Chloroprocaine AND Prilocaine Fine-tuning spinal anesthesia Patient Surgery-Surgeon

38 Prilocaine vs Chloroprocaine?

39 Local evolution Vials HB Years

40 Chloro-procaine NB : Fast Prilocaine HB: Medium Marcaine HB : Long Conclusion adjuvants Baricity-Positions doses indications

41 Conclusion Surgeon Local organization Nurses Anesthesiologists feel free to perform adapted spinal anesthesia the right dose of the right drug in the right place For the right surgery and with the righ (Editorial BJA 2005)

42

43 you for your attention Thank Hyperb aric Prilocaine??